NURSING the FUTURE E-Learning and Clinical Care, in Kenya by Angela Nguku Printed by 4 Print Ltd

POLICY VOICES SERIES POLICY

NURSING THE FUTURE e-Learning and clinical care, in Kenya By Angela Nguku Printed by 4 Print Ltd. KT8 2RY 020 8941 0144 The Author The Policy Voices Series

Angela Nguku joined the African Medical and Research The Policy Voices Series highlights instances of personal Foundation (AMREF) in 2005, while working in achievement with wider implications for policy makers Southern Sudan. She was appointed as the first in Africa. coordinator of the AMREF Virtual Nursing School In publishing these case stories, Africa Research Institute (AVNS) in 2007. seeks to identify the factors which lie behind successful Angela was born in 1979 in Nthongoni village, Makueni interventions and to draw policy lessons from individual district, in Kenya’s Eastern Province. She attended experience. Precious Blood, a provincial Catholic school where she This series seeks to encourage competing ideas, completed her secondary education at age 17. After discussion and debate. The views expressed in the Policy school, Angela enrolled at the University of Nairobi Voices Series are those of the author, and not those of Medical School to study for a Bachelor of Science in Africa Research Institute. Nursing, where she graduated with honours in 2003.

After an internship at Kenyatta National Hospital, Angela moved to Southern Sudan where she joined Action Africa, Acknowledgements a German development charity, in a project to train local Africa Research Institute would like to acknowledge the health workers in reproductive health. For AMREF, cooperation and encouragement of Dr Peter Ngatia, Angela was involved in setting up the the first midwifery Caroline Mbindyo, Mary Mbugua, Martin Kinyua and school in Southern Sudan, under the auspices of the Phillip Ngare at AMREF in Nairobi. Elizabeth Oywer, National Health Training Institute. She was a member of Registrar of the Nursing Council of Kenya, and the curriculum development team which introduced an Philomena Maina, Chief Nurse at Kenyatta National 18-month classroom programme in midwifery. Graduates Hospital, readily shared their time and insights. In from the programme are working in health institutions London, the advice and contributions of Jennifer Stobart across Southern Sudan. at AMREF UK and Matthew Edwards at Accenture were invaluable. This manuscript was compiled from AVNS is a nursing school established by AMREF in 2007 transcripts of interviews with Angela Nguku, with editing to improve the clinical and management skills of nurses in and additional research by Jonathan Bhalla. Cover design Kenya. The aim of AVNS is to develop practical guidelines by Krishna Stott. Editing and publication was managed and to encourage best practice in e-learning programmes by Aoiffe O’Brien. The project was made possible by the administered by nursing schools across the country. generous assistance of Richard Smith. Angela is currently studying for a master’s degree in nursing leadership and management, via distance Published by Africa Research Institute, 2009 learning, at the University of Dundee, Scotland. ISBN No. 978-1-906329-06-8

Africa Research Institute is a non-partisan think tank based in London. Our mission is to draw attention to ideas which have worked in Africa, and to identify areas where new ideas are needed.

For more information please visit our website: www.africaresearchinstitute.org 43 Old Queen Street, London SW1H 9JA, UK

1 e-Learning and clinical care, in Kenya

CONTENTS

Foreword 4 By Mark Ashurst Director, Africa Research Institute

1. Introduction 7

2. A system under strain 7

3. The skills shortage 8

4. A hierarchy of training 8

5. The challenge: 22,000 nurses, nine years 9

6. Distance learning 10

7. The burden of print 10

8. A bright idea 11

9. Accenture 12

10. e-Learning 12

11. Growing pains 13

12. Responses 14

13. Clinical congestion 14

14. The next hurdle 15

15. AMREF Virtual Nursing School 15

16. Partnerships 15

17. The mobile support network 17

18. The student to tutor ratio 17

19. Output and achievements 18

20. Funding and governance 20

21. The brain drain 21

22. Recommendations 22

3 Nursing The Future

Foreword Angela Nguku, coordinator of AMREF’s Virtual Nursing School (AVNS), shares many of the characteristics of the Nothing more needs to be said about the promise of nurses who are her students: she is a busy, practical, information technology to transform developing societies. no-nonsense kind of teacher. For Angela, much of the talk The precedents are encouraging. Across Africa, cellular of ‘designer’ technologies for Africa is exaggerated. She phones have brought instant communication to previously has no time for the fantasies of science fiction. AVNS, isolated villages. Market traders and rural farmers can for created in 2007, is both a laboratory and an incubator for the first time gain up-to-the minute pricing from markets the ongoing experiment that is e-learning in Africa. Its and manufacturers in the industrialised world. Internet electronic content avoids the costs and administrative kiosks, linked via satellite to cyberspace, cater to the burden of textbooks, but follows the same syllabus as growing demand for access to email even from small traditional classroom teaching, set by the Nursing Council towns and desolate highways. of Kenya. The basic premise of e-learning for clinical

The next step is to demonstrate that electronic practitioners, then, is more organic evolution than a communication can leapfrog old ways of learning. If that radical break with the past. notion is no longer fanciful, it is equally true that much In common with every African nation, Kenya is severely remains to be proved. How, when and where technology affected by a shortage of clinical skills to tackle the can be applied to best effect are questions which invite a epidemics of the 21st century. Most of the country’s dizzying array of ideas and possibilities. Hundreds of 22,000 ‘enrolled’ nurses – the standard minimum nursing distance learning schemes are already underway, with qualification in Kenya – received their training before similarly varied results. From the pilot projects of South they were called on to treat complications and diseases Africa’s Industrial and Scientific Research Council in arising from chronic conditions such as HIV/AIDS, Pretoria, to Senegalese president Abdoulaye Wade’s malnutrition and poor sanitation in urban slums. ambitions for a high-tech university on the Atlantic coast at Dakar, it remains an immense challenge to translate The dimensions of the problem are well understood ideas into concrete results. by the ministry of health and the Nursing Council of Kenya. In 2001, they adopted a policy intended to The Policy Voices Series examines the policy implications upgrade the clinical skills of the country’s enrolled nurses arising from the experience of innovators in Africa. This – then estimated at 26,000 – to the higher standard of a paper considers the work of an organisation, chronicling ‘registered’ nurse by 2010. The estimated number of what must be the ultimate test of any distance-learning enrolled nurses was subsequently revised to 22,000. A programme: to achieve new standards of clinical care related plan to phase out the basic qualification for from hard-pressed nurses on the front line in Kenya’s enrolled nurses has not been pursued. For AMREF, busy hospitals and clinics. Mindful of that challenge, the however, the objective is unchanged: an e-learning African Medical and Research Foundation (AMREF) has programme to deliver a high output of trained nurses in a devised an e-learning programme supported by local short period of time. Close links to physical infrastructure instructors in nursing schools and other clinical centres enable nurses to train while continuing in full-time work across Kenya. If a computer-based syllabus can be at hospitals, health centres and dispensaries. effective in training clinical staff, within stringent criteria regulated by the Nursing Council of Kenya, surely other The e-learning methodology is recognised by the professions will find much to emulate in their example. ministry of health and regulated by the Nursing Council of Kenya. Both institutions are represented on the

4 e-Learning and clinical care, in Kenya steering committee which oversees distance learning. A larger and so far intractable deterrent is the cost of AMREF secured financial and technical support from tuition. The two-year programme to qualify as a Accenture, the global management consulting, registered nurse costs each student about US$1500. technology services and outsourcing company, building Average salaries for an enrolled nurse are in the range of on AMREF’s record in medical education and US$100-US$250 per month, dependent on employer, Accenture’s commercial experience in e-learning and experience and location. Most nurses in Kenya work software design. The partnership unlocked about US$3m either within the public sector, private or faith-based in financial and technical support from Accenture and institutions. For nurses such as Anne Kamene, a single Accenture Foundations – a record commitment both in mother of two with no savings and an elder child already cash terms and in the scale of pro bono contributions at university, more professional training involves a from technical staff. Accenture created bespoke teaching massive investment. Nor is there any guarantee of better materials and technical infrastructure to support rates of pay for registered nurses. In common with other successive versions of the programme from its launch in African states, Kenya lacks both resources and September 2005. appropriate structures adequately to remunerate improved skills. Most graduates have waited, often several years, For student nurses, AMREF’s course can seem daunting. for a pay rise. Resistance to technology – sometimes verging on “technophobia,” according to Angela – proved a frequent As this paper goes to press, about 600 Kenyan nurses obstacle. Students are offered training in basic computer have qualified via e-learning, with a further 5,798 in skills – a mandatory requirement for all applicants. Anne training to become ‘registered’ nurses. Only a portion of Kamene, a nurse who relates her own story in these pages, these will complete their studies via e-learning, first set hands on a computer at AMREF: “I’m not supplemented by periods of clinical training in teaching computer literate, but I can use a computer to run the hospitals and other centres of care. The incidence of programme,” she recalls. After countless delays, failure and of drop-outs from the e-learning course AMREF’s goal of supplying one laptop per student is remains worrying high, both for its architects at AMREF now in prospect, helped by an arrangement to import and for the ministry of health and the Nursing Council of discounted second-hand laptops from Computer Aid, a Kenya. In spite of these problems, however, their work UK charity. begins to address the serious shortage of up-to-date clinical skills among nurses in Kenya. Improved access to computers is crucial to realise the chief advantage of e-learning, namely the prospect of The precedent is both important and, in a larger sense, achieving far greater reach by increasing the ratio of inadequate. Tackling the problem of outdated skills does student nurses per tutor beyond the classroom maximum not, of course, target the more formidable issue of the of 20:1 stipulated by the Nursing Council of Kenya. For general shortage of nurses in every African country – AVNS, this quota has been increased to 50:1 – a although the precedent of successful e-learning may yet significant concession, but also a measure of caution on play a part in making good that deficit. AMREF’s the part of the regulatory authority. Dr Peter Ngatia, methodology has provoked interest from neighbouring AMREF’s director of capacity building, is optimistic that countries in East Africa, from Rwanda, and parts of in the longer term, as the pedagogy is refined, a ratio of southern and West Africa: all regions where technological more than 50 students per tutor can be achieved. infrastructure is limited and unreliable, but vested with the high hopes of local communities. “E-learning is a big

5 Nursing The Future step in the right direction for Kenya,” says Elizabeth social networks after graduation. International policy Oywer, registrar of the Nursing Council of Kenya. makers should look hard at the precedent, and its prospects. In a recent survey of graduates from the AVNS programme, 20 out of 27 respondents expressed Mark Ashurst enthusiasm for migrating to a better paid job abroad. Director, Africa Research Institute According to most estimates, Kenya will not meet any of the Millennium Development Goals for health by 2015 – goals adopted by the United Nations and G8 group of industrialised countries, and backed by funding commitments scheduled to reach US$50 billion a year for Africa. As skilled health professionals seek better paid roles in developed countries, innovations such as e-learning may gain new significance in the ongoing debate over development policy.

The policy implications of e-learning are not confined to Africa. In a global village, international relations require constant negotiation. Already, high speed data connections link African companies to new clients in the higher-waged-metropolitan centres of the rich world. A fledgling industry of new call centres and administrative offices – ‘back office processing’, in corporate jargon – has taken root from Cape Town to Kampala. If such cooperation can work in business, why not in the public realm – most especially in education and skills training?

These are early days still for AMREF’s e-learning programme, but the record to date raises the possibility of a viable mechanism for reparations to make good the loss of skilled migrants from African health systems. Industrialised nations could yet subsidise the cost of replacing lost skills by training one new nurse for every (tax-paying) migrant to a hospital in Europe or the United States – a quid pro quo which might provide a model for other sectors struggling to replace local skills lost to the ‘brain drain’.

It may even emerge, as early evidence from Kenya suggests, that a training method which enables nurses to continue to live and work in local communities will, in turn, reduce their enthusiasm to leave family and other

6 e-Learning and clinical care, in Kenya

1. Introduction for innovation and best practice, from which practical guidelines for e-learning can be developed and shared In 2003, after a four-year course at the University of with other schools. AVNS is administered and funded Nairobi Medical School, I graduated with a Bachelor of entirely by AMREF. Science in Nursing. The syllabus had been designed as a five-year programme of study, but was condensed in an Our e-learning programme was developed initially by my effort to boost the number of skilled nurses in Kenya. Our colleagues at AMREF in partnership with Accenture, a work was concentrated into an extended academic year global management consulting, technology services and spanning 44 weeks. At weekends, I found a part-time job outsourcing company.1 The advantage of e-learning is its to cover my living expenses. A higher education potential to train a high number of nurses in a short period loan from the bank paid for tuition fees and of time. Nurses with the most basic level of training, an accommodation costs. Enrolled Community Health Nursing Certificate, are able to upgrade the theoretical component of their training to Since completing my degree, I have seen the extraordinary the level of the Registered Community Health Nursing investment and sacrifice made by many students of Diploma, without attending classes or leaving their jobs. nursing – in Kenya, and further afield. Much of my career Course materials can be loaded from DVD onto any has been spent educating other nurses. In early 2005, I computer. Students can follow the course in their own travelled to Southern Sudan to carry out a survey of time, supported by tutors who monitor their progress maternal and reproductive health for Action Africa Help remotely. International, a German charity. Subsequently, we implemented a programme to reduce maternal mortality, Prior to 2005, when the first distance learning schemes in which I trained Sudanese health workers to build local were introduced for nurses, many would-be students were skills and capacity. The experience convinced me of the deterred from studying for a higher nursing qualification huge difference which improved clinical care can make, because they lived too far from a nursing school. The from the earliest stages of human life. traditional classroom-based schools were able to train a maximum 150 registered nurses each year, making little In Sudan, I joined African Medical and Research impact on Kenya’s huge deficit of skilled medical staff. Foundation (AMREF), Africa’s largest non-governmental By 2009, the combined capacity of Kenya’s various organisation (NGO) in the health sector. I worked in a institutions and initiatives to train registered nurses had team which set up the first midwifery school at the reached almost 600 per year. The rate of increase is slow, National Health Training Institute in Southern Sudan. My relative to the need, but we are making progress. first hands-on experience of devising training programmes was to develop an 18-month course in midwifery for nurses. 2. A system under strain

In 2007, I returned to Nairobi to take up a new position The Kenyan health sector is ill-equipped and with AMREF as course coordinator for the new AMREF under-staffed to meet the needs of a population which has Virtual Nursing School. AVNS is part of an innovative doubled in size since 1980. The HIV/AIDS pandemic nationwide e-learning programme pioneered by AMREF. places a heavy burden on the system: AIDS-related Other health institutions participate in the programme, conditions are the country’s biggest killer, accounting for and AVNS is one of 32 nursing schools in Kenya which 38% of all deaths in Kenya each year.2 Respiratory offer e-learning programmes. We try to be an incubator infections, diarrhoeal diseases, tuberculosis and malaria

1. References to Accenture include Accenture Ltd and its subsidiaries as well as independent charitable organisations that bear the Accenture name. 7 2. World Health Organisation, www.who.int/countries/ken/en/ Accessed June 2009 Nursing The Future claim a further 27% of annual deaths, although in a vast Two thirds of the nurses in Kenya hold only an enrolled majority of cases these conditions are treatable. The key nursing certificate, the minimum nursing qualification. measures or health indicators in Kenya remain better than Many enrolled nurses completed their training before those of many other sub-Saharan African countries, but HIV and tuberculosis became widespread. They are not they are deteriorating. Predictions by Britain’s trained in the management of infectious diseases. The Department for International Development (DFID) curriculum for the enrolled nursing certificate is outdated. indicate that Kenya has very little or no chance of It has not kept up to date with developments in nursing achieving any of the Millennium Development Goals in practice and disease management. health by 2015.3 At any one time, up to 60% of public hospital beds in Kenya Most patients are required to pay for treatment. Spending are occupied by HIV/AIDS patients – yet most Kenyan on public health is equivalent to approximately US$5 per nurses have no training in diagnosis and management of capita – well below the US$20 often cited as a bare their condition. The World Health Organisation has minimum to deliver essential services. Government identified the “acute shortage of trained health workers, institutions provide free care for only the most basic especially in rural areas” as one of the largest barriers to medical procedures. Any more specialised treatment improving care for people infected with HIV. invariably incurs a charge. Although most private health Enrolled nurses are trained in basic midwifery, but they institutions have a good reputation for their standards of are not taught how to manage complications during care, they tend to be costly and beyond the reach of most childbirth. The rate of maternal mortality is high and Kenyans. Faith-based and charitable institutions often rising in Kenya. About 15% of women aged 15-40 die provide cheaper health services than the private sector, during childbirth. subsidised by donations, but their services are rarely free of charge.

The quality of care varies greatly from urban to rural 4. A hierarchy of training areas. Rural health facilities tend to be smaller, and are Training as an enrolled nurse is the quickest and cheapest usually limited to clinics or dispensaries. Most lack of three routes to becoming a nurse in Kenya. Two capacity in both skilled personnel and medical equipment. alternative courses – Bachelor of Science in Nursing, and When staff encounter complicated illnesses, they refer the registered nursing diploma – take longer to complete, patients to a larger hospital in an urban area. About 60% with no guarantee of higher wages. In 2005, 66% of of nurses work in rural areas. Most are enrolled nurses, Kenyan nurses held an enrolled nursing certificate. Only trained to perform only basic procedures. 6% held a degree.

The enrolled nursing certificate takes two and a half years 3. The skills shortage to complete. Training includes general nursing, community health and basic midwifery. Nurses learn to The standard and scope of care is constrained by a manage discomfort, to feed and bath patients, to hand out shortage of skilled health workers. Kenya counts about prescribed medication, and to assist doctors during minor 33,000 nurses, in a population of just under 35 million. surgical procedures. That is equivalent to around one nurse for every 1000 people. In the UK, the equivalent figure is just short of Enrolled nurses are required to act only when instructed 13 nurses for every 1000 people. 4 by doctors and senior nurses. They can administer

8 3. Three year plan for Kenya, 2004, UK Department for International Development, www.dfid.gov.uk/Where-we-work/Africa- Eastern--Southern/Kenya1/ 4. World Heath Organisation, www.who.int/countries/gbr/en/ e-Learning and clinical care, in Kenya medication prescribed by doctors, but they are not taught The degree course is expensive, but provides nurses with about the rationale behind doctors’ prescriptions. Why is an array of career options, which extend beyond clinical this medication necessary? What is a safe dose to take? care. Degree nurses are trained to be hospital managers, What are the side effects? They rely on registered nurses teachers and researchers. These skills are crucial because or doctors to answer these questions. senior nurses assume a leading role in the provision of clinical care in Kenya. They support doctors in clinical The registered nursing diploma takes three and a half areas, while also taking responsibility for the years to complete and prepares students for all aspects of management of hospital wards. clinical care. It is a much more expensive course for students. Registered nurses can obtain senior positions in hospitals and health centres, but often do not receive 5. The challenge: 22,000 better wages than enrolled nurses. In 2005, there were nurses, nine years only 4,000 registered nurses employed in Kenya. In 2001, the Nursing Council of Kenya (NCK) and The registered nursing diploma includes training in ministry of health (MOH) issued a joint statement specialised medical fields, such as mental health and announcing their intention to train all enrolled nurses in infectious diseases. Registered nurses learn to conduct Kenya to the higher standard of registered nurse by 2010.5 research into new and re-emerging medical conditions. At that time the number of enrolled nurses in the country They acquire a variety of management skills, from was estimated at 26,000, but was subsequently revised to coordinating hospital staff to developing filing systems 22,000. The statement acknowledged a need to improve for patients’ medical records. Once qualified, they are and to standardise the quality of clinical care provided in authorised to manage hospital wards. health institutions. The Kenyan authorities acknowledged that the basic qualification of enrolled nurse failed The Bachelor of Science in Nursing, the highest adequately to prepare nursing staff to confront the qualification, takes five years to complete, including a country’s emerging health problems. one-year internship. The Bachelor was introduced by the Nursing Council of Kenya (NCK) in 1994 as a response The NCK, the body mandated to oversee the training of to the shortage of highly skilled nurses and teachers. The all nurses in Kenya, was aware that it would not be able government needed to train as many nurses as possible to to reach the target alone. The capacity of nursing schools degree level. was limited. They could train only between 100 and 150 enrolled nurses to the standard of registered nurse each The Bachelor of Science in Nursing is unlike any other year. To achieve its goal of training 22,000 enrolled nursing qualification. It is a comprehensive course, under nurses in nine years, the NCK would need to train about which student nurses are required to gain a minimum of 2,450 nurses each year. 62 weeks of clinical experience in the principal areas of care, namely: The NCK turned to AMREF, Africa’s largest health • Anatomy and physiology non-governmental organisation, for help. AMREF has • Pharmacology and biochemistry experience in designing education programmes, • Virology and immunology particularly distance learning, in several African • General nursing and specialised nursing disciplines countries, coordinated from our headquarters in Nairobi. • Community health One of AMREF’s main objectives is to strengthen the • Midwifery and reproductive health capacity and capability of health institutions in Africa.

5. Under the coalition government formed in 2008, the ministry of health has been divided into two separate ministries: ministry of medical services and ministry of 9 public health and sanitation Nursing The Future

The scale of the challenge was daunting. AMREF had Face-to-face interaction has not been abandoned. never designed a programme of this magnitude before. It Although distance learning eliminates much of the was clear that it would not be possible to train all 22,000 methodology of the classroom, the e-learning programme nurses in classrooms. Kenya does not have enough includes opportunities for students to meet with their nursing schools, teachers or training hospitals to sustain teachers. Nurses are required to attend school for two a large classroom-based programme. weeks of tutorials for each module. If nurses have difficulties with an aspect of the course, they can visit a Most nursing schools are located in urban centres or small distance learning tutor at the nursing school. Nurses towns, but most enrolled nurses live in rural areas. They complete a mandatory 48 weeks of clinical experience at are not always in a position to commute to a school, the closest teaching hospital. particularly where transport infrastructure is poor. Nor can most nurses afford to take two years out of work to The distance learning programme substantially increased return to education. Nurses who wanted to return to the intake of enrolled nurses studying for a registered nursing school often transferred to an urban area, where nursing diploma. By June 2004, 570 students had been they could continue to work while studying. admitted to the course, a five-fold increase on admission to the NCK classroom programme.

6. Distance learning The textbook-based distance learning programme had moved Kenya a long way towards overcoming the It soon became evident to my colleagues at AMREF that difficulties associated with further education for working the only prospect of achieving the target set by the NCK nurses. Although I was not involved in this aspect of and the MOH was to adopt distance learning. In 2003, AMREF’s work, I can appreciate its important AMREF designed a programme to train enrolled nurses achievements: remotely. The course is available through nursing schools, but there are no classroom lessons. • No regular classroom lessons; nurses are not required to leave their jobs and become full-time students. Nurses follow four textbooks – one for each of the course • Access for nurses from rural areas; nurses are required modules, which guide nurses through the theoretical to attend nursing school only intermittently. requirements of the registered nursing diploma. The four • Flexibility; textbooks enable nurses to study at home in modules cover all subjects required by the NCK their own time. curriculum: • Clinical practice; students practise clinical care in their daily work by applying skills learned from their training. • First module: general nursing, paediatric and adult clinical care. • Second module: reproductive health, midwifery, sexually transmitted diseases and contraceptive 7. The burden of print technology. The distance learning programme is burdened by the cost • Third module: community health, community needs of textbooks. The ministry of health does not provide assessments and infectious disease treatment. extra funds to meet the cost of additional textbooks. The • Fourth module: specialised nursing areas, mental health cost of printing has deterred nursing schools from care, management training, research and teaching participating in the programme. methodologies.

10 e-Learning and clinical care, in Kenya

e-Learning: key dates dropped to 95, from 570 in the previous year. In March 2005, the tally of admissions rose to 280, still only half 2000: Nursing Council of Kenya (NCK) holds talks the intake of the first year. It became clear that these with the ministry of health (MOH) to discuss the shortage of skills among enrolled nurses. courses would not train sufficient nurses to meet national targets. AMREF began to explore alternative ways to 2001: NCK and MOH release joint statement acknowledging the urgent need to retrain 26,000 expand the distance learning programme. enrolled nurses to the standard of registered nurse, by 2010. (Subsequently revised to 22,000) 2002: NCK approaches AMREF for assistance in 8. A bright idea designing a programme to retrain all of Kenya’s enrolled nurses. In 2004, AMREF began to consider electronic teaching

2003: AMREF designs a distance learning methods, or e-learning, as an alternative to textbooks. The programme based on printed textbooks. idea of developing a computer-based e-learning

2004: AMREF approaches Accenture for assistance programme for the registered nursing diploma originally in designing an e-learning programme for came from South Africa. Dr Peter Ngatia, head of enrolled nurses. capacity building at AMREF, told a colleague at the 2005: Accenture agrees to provide funding and University of Pretoria in South Africa about the technical support to developing an e-learning programme. The pilot project begins in difficulties AMREF had experienced in devising a September. distance learning programme to address the scale of the

2006: Nationwide e-learning begins in March, with skills deficit among Kenyan nurses. participation of 32 nursing schools. The University of Pretoria has developed a master’s 2007: AMREF Virtual Nursing School (AVNS) is founded. Based at AMREF headquarters, AVNS programme for public health workers through e-learning. focuses only on e-learning for enrolled nurses. Students download course material from the internet to

2010: Accenture funding worth US$1.9 million due to study in their own time. Three thousand students were expire. registered on the programme in 2004, demonstrating that e-learning could support large number of public health Printed textbooks are difficult to improve and update. If workers in training at the same time. the learning material needs to be changed, new textbooks The application of the e-learning model in Kenya was far have to be printed. The NCK reviews the curriculum for from straightforward, as I would subsequently discover nursing education every four years. Since the beginning in my work to set up a dedicated AMREF Virtual Nursing of the programme in 2003, AMREF has made suggestions School (AVNS). The idea of training nurses through to the NCK for improving the registered nursing computers is a totally new concept. No public policy curriculum. It is difficult, logistically and financially, to existed to support e-learning initiatives. Kenya has poor print new textbooks each time the curriculum is updated electricity and internet connectivity, particularly in rural or changed. areas. For all its achievements in public and community Many nursing schools continue to run print-based health, AMREF had no experience in computer-based distance learning programmes. They find the education and lacked technical skills to develop an methodology allows greater flexibility than classroom e-learning programme. learning, although many rural nurses have not heard of distance learning. In September 2004, admissions

11 Nursing The Future

9. Accenture jointly by Accenture and AMREF. Two AMREF staff members, and a representative from the NCK, travelled to Fortunately, help arrived in the form of Accenture, the the UK for training by Accenture Learning Services in business consultancy and technology services company, computer programming. Two Accenture staff came to which has contributed both technical skills and financial Nairobi to work with a team from AMREF to develop resources to roll out a computer-based programme across learning materials. From this process, AMREF staff have the country. acquired the skills to develop our own content for

We turned to Accenture on the advice of Matthew e-learning. Edwards, a director of AMREF UK, who is also a senior Computer-based learning follows the distance learning executive at Accenture. With his assistance, AMREF’s model but cuts out the paper. Course materials such as main fundraising office, in London, worked closely with nursing theory are loaded into software which can be my colleagues in Nairobi to prepare a fundraising accessed by student nurses in their own time. Computer proposal. The proposal was submitted to the Corporate ‘labs’ are set up at nursing schools and other health Citizenship Council of Accenture, which reviews all facilities. AMREF will set up a computer lab for any applications for charitable funding. health facility where at least five nurses want to join the

In 2005, Accenture agreed to become a partner in the programme. Nurses on to the e-learning course are programme. A cash contribution was made available by permitted entry to any computer lab in the country. Accenture Foundations, the company’s charitable trust The software can be run on a personal computer without funds. Accenture Learning Services, a commercial branch an internet connection. In the long term, I am keen to see of the company, provided IT support and management the entire programme made available online. This would expertise. allow a greater number of nurses to train simultaneously, but it is not a priority at this stage. Internet connectivity 10. e-Learning is not yet sufficiently widespread: only 5% of Kenya has internet coverage, mostly in urban areas. The computer-based training methodology was launched in 2005, with a one-year pilot programme based on the Kenya, distribution of training centres and nursing schools first of the four distance learning course modules. Accenture developed the software for the pilot study which involved 145 students from four teaching centres, namely:

• Moi Teaching and Referral Hospital Training College, Rift Valley Province. • Mombasa Medical Training College, Coast Province. • St Elizabeth Nursing School, Mukumu, Western Province. • Kakamega Medical Training Centre, Western Province.

While the pilot study was under way, the electronic content for the remaining three modules was developed Source: AMREF

12 e-Learning and clinical care, in Kenya

Accenture and AMREF By Matthew Edwards Senior executive in financial services, Accenture Ltd

I have a long and personal relationship with AMREF. I colleagues and I worked with AMREF to develop a spent much of my childhood in Africa, as my father proposal for the Accenture Foundations. worked for the UK’s Overseas Development Agency, the predecessor to the Department for International In 2005, the Accenture Foundations agreed to support Development. Over the past four years, I have facilitated the e-learning programme with US$1.7 million in cash. the relationship between Accenture and AMREF. Accenture agreed to provide a further US$1.2 million in pro bono services, primarily for the development of My father approached me, in 2004, with the idea of the e-learning software. Accenture Learning Services, developing an e-learning programme to train Kenyan the company’s e-learning specialists, agreed to nurses in full-time employment. He was aware of provide personnel for the programme development. It AMREF’s efforts to train nurses from his role on the took a year to develop a fully functional e-learning charity’s board of trustees. I was immediately programme that could be used to train nurses. interested, as the programme seemed to be an excellent fit with Accenture’s corporate citizenship e-Learning for Kenyan nurses is a pioneering objectives. programme for Accenture. It is our most ambitious programme in terms of the scale of the cash grant and Corporate citizenship has become an increasingly the level of employee involvement. important part of Accenture’s way of doing business. In 2001, Accenture became a publicly listed company Accenture and AMREF don’t have a traditional on the New York Stock Exchange and a number of donor-recipient relationship. It has been a partnership former senior partners decided to donate shares to between the two organisations, each working on our the Accenture Foundations, to fund a Global Giving respective strengths. At Accenture, we have the skills Programme. Accenture takes corporate citizenship to develop e-learning software. AMREF did not. But very seriously. the programme would never have been possible without AMREF’s expertise in training medical As always, Accenture needed to understand the professionals in Africa, and managing complex feasibility of the programme. We sent two employees, relationships with the Kenyan government. who were familiar with Accenture’s e-learning capabilities, to Nairobi to hold a workshop with There have been challenges along the way but, AMREF and the Nursing Council of Kenya (NCK). working jointly with AMREF, we have addressed them. Once we were confident that the programme was We are all pleased with the progress made in possible, a funding proposal was developed. My improving nursing training in Kenya.

If nurses have difficulties with the course material, they 11. Growing pains can seek help from tutors at nursing schools. As in the Four areas of difficulty emerged from the pilot study, print-based distance learning programme, students are although the overall findings encouraged AMREF to expected to attend nursing school for two weeks of pursue the project. The core areas of concern included: tutorials per module.

1. Computer literacy: the programme assumed that tutors Clinical experience is a key component of the training and students would be able to adapt to e-learning. Most and is planned at the beginning of each course. Nurses tutors and students had never used a computer before, who work at small health centres are given clinical lacking the most basic IT skills. Student nurses were placements at the closest teaching hospital. Replacement not visiting the computer labs on a regular basis. nurses are sent to cover for their absence, as the rural services are often short-staffed. 2. Tutor scepticism: tutors were doubtful that computers could be used to train nurses. These nurses had been teaching for more than 20 years in a classroom. From

13 Nursing The Future

their perspective, computers were for young people. Basic IT training has served two main functions: The transition from classroom teacher to an e-tutor is 1. Increased the total time spent by student nurses in the an uncomfortable behavioural change for many senior computer labs. nurses.

2. Convinced older nurses of the merits of the e-learning 3. Technical faults: computer labs regularly experienced methodology. technical problems which neither the students nor the teachers could fix. Computers would be sent back to The problem of technical faults experienced in the pilot Nairobi for repair with only minor problems, which prompted AMREF to develop a three-tiered system of IT would have been avoided if nurses had basic IT support. Technical faults are first seen by e-learning tutors, training. By the time replacement computers were sent trained in IT support. If tutors cannot fix the computer, the to the computer labs, students had fallen behind in their problem is referred to an IT specialist stationed at nursing studies. schools. We have trained an IT specialist for each nursing school which participates in e-learning. If the problem 4. Clinical congestion: teaching hospitals were beginning persists, the computer is sent for repair to an IT helpdesk to experience congestion in clinical areas. The at AMREF headquarters in Nairobi. To date, we have registered nursing diploma requires nurses to complete dedicated three IT technicians to the e-learning relevant clinical assessments for each module. Nursing programme. All matters that cannot be resolved by the schools encountered difficulties in finding clinical schools or AMREF are referred to Accenture. placements for the increased number of enrolled nurses on the e-learning programme. The number of teaching hospitals approved for training purposes is limited. 13. Clinical congestion Clinical placements in teaching hospitals are in high demand from all medical students, not just nurses. We are making ongoing efforts to increase the availability of clinical placements. NCK guidelines state that student nurses must undergo 48 weeks of clinical training to fulfil 12. Responses the requirements of the course. The only way to ensure enough clinical places for student nurses is to increase the The scepticism of tutors and the difficulties of student number of approved teaching hospitals. nurses in the pilot study were caused largely by poor computer literacy. Most Kenyans are not familiar with The NCK agreed to review the status of health facilities computers. Nurses did not make best use of the computer all over the country, particularly those in rural areas. In labs during the study, because their IT training was the last four years it has approved more facilities for limited. teaching proposes, boosting the number of clinical placements available for nurses. Some health facilities are In response, AMREF now hosts one-week IT training approved for teaching purposes only in specialised fields, sessions for e-learning tutors every March and September. such as paediatrics. The sessions cover a broad range of IT skills: from how to switch on a computer, to fixing minor technical faults. In spite of these initiatives, clinical congestion remains When a new class of nurses enrols on the e-learning an ongoing problem. Simply put, there are not enough programme, tutors spend the first week teaching them IT teaching hospitals in Kenya to realise the ambition of the skills. various training programmes. Student nurses, particularly

14 e-Learning and clinical care, in Kenya those in rural areas, often struggle to find clinical AMREF collects feedback twice a year from each nursing placements in nearby hospitals. It can take months for the school in the e-learning programme. My role at AVNS is NCK to determine whether a health facility is fit for to develop and test solutions to ongoing problems with teaching purposes. the e-learning methodology. From this work, we are able to develop useful guidelines for future practice.

14. The next hurdle We report our findings to the nursing schools, detailing what has worked for AVNS and what has not. The AVNS Nursing schools continue to experience problems with team make suggestions to nursing schools based on their the e-learning methodology. Some are common to all individual circumstances. AMREF is constantly looking nursing schools, while others emerge only in a particular to improve the e-learning methodology. region or institution. AVNS has a bi-annual intake of fifty student nurses from AMREF does not have ready-made answers to these all over the country, in March and September. Four tutors problems. This is the first time an e-learning programme are dedicated to the e-learning programme at AVNS, of this scale has been attempted in Kenya. There is no including myself. AVNS is unique in being the only definitive programme to which we can refer for guidance. nursing school in Kenya that is not attached to a teaching Many of the challenges faced by nursing schools are hospital. All AVNS student nurses are required to unique to developing countries. I often find that it takes complete clinical placements in approved health facilities, time to work out solutions. although placements are dependent on availability.

AMREF decided to develop a system for testing responses to problems encountered by nursing schools 16. Partnerships running the e-learning programme. Significant responsibility for developing this system was assigned to My first task at AVNS was to find clinical placements for me, in my new role as coordinator of AVNS. We want to all of our student nurses. In 2007, AVNS reached be confident in the outcome of any recommendations we agreement with the ministry of health (MOH) to allow make to the schools, because their implementation often our student nurses to book clinical placements in any involves a financial commitment. Nursing schools are not government teaching hospital. Kenya Medical Training in a position to take financial risks, and must be prudent College, for example, is the largest government medical in managing their finances. school in Kenya, with a large training hospital in Nairobi and 32 smaller training centres across the country. AVNS students can book clinical placements in any of these 15. AMREF Virtual Nursing training hospitals.

School The development of partnerships with outside health The AMREF Virtual Nursing School (AVNS) was facilities is paramount in the work of AVNS. We have established in January 2007 to develop practical solutions to developed individual partnerships with private and new and persistent challenges. Based at AMREF faith-based teaching hospitals in Nairobi and other parts headquarters in Nairobi, AVNS is a nursing school which of the country. These partnerships have greatly increased trains enrolled nurses through e-learning. It receives no the number of clinical placements on offer to AVNS government funding and is solely administered by AMREF. students. No other medical training programmes are taught at AVNS.

15 The NCK and e-Learning

By Elizabeth Oywer Registrar Nursing Council of Kenya

Kenya’s health system has come a long way over the I was determined that the e-learning programme last 50 years. We have developed our own systems for would succeed. We did not have all the answers, but I training all types of health professionals, from decided we would learn as we went along. I believe it scratch. This process has taken longer than we is important to take risks. I personally made sure that anticipated, particularly in nursing. the programme was approved within the NCK and MOH. Today, the numbers speak for themselves: more Kenya began to train senior nurses in administration, than 5,000 nurses are training for a registered nursing teaching and management in 1968. Until then, nurses diploma. had to travel abroad to learn these important skills. But progress has been slow. The Bachelor of Science The e-learning programme is a work in progress. in Nursing degree was only introduced in public Capacity could be improved in important ways, universities in 1994, some 20 years later than was including: initially planned. • Helping nurses to pay tuition fees. Nurses are The Nursing Council of Kenya (NCK) is mandated to required to pay about US$1,500 to participate in the regulate nursing care and practice in Kenya, but our e-learning programme, an expense that many cannot capacity to train senior nurses is low. In 2005, there afford. Tuition fees have been a real barrier for were only 4,000 registered nurses and 2,000 degree nurses wanting to enrol on the e-learning nurses. Today, I can count the number of nurses with programme. PhDs on one hand. • Increasing the number of teaching hospitals. Nurses The lack of training capacity explains why the vast are struggling to find placements for clinical majority of nurses in Kenya hold only an enrolled assessments. The NCK visits ten hospitals every nursing certificate, the basic nursing qualification. quarter, but ensuring they are fit for teaching Clinical training for enrolled nurses is brief, and does purposes is an arduous process. not include teaching, management or research. Important medical skills, such as midwifery, are not • Increasing the number of computers available to taught in adequate detail. student nurses. Currently, there is one computer for every five nurses. In an ideal world, each nurse would Enrolled nurses need to be taught clinical and have their own laptop, so he or she could study at management skills. I joined the NCK in 2003, two home and at work. years after the council had set a target to re-train all enrolled nurses by 2010. Nursing schools had The first concern for the NCK is to ensure that every the capacity to re-train only between 100-150 registered nurse is trained to the highest possible enrolled nurses each year. It was essential to shift to standard. The size of classes must be regulated. remote learning because it would have been AMREF wants to increase the student to tutor ratio impossible to meet our target by the traditional from 20:1 to 50:1, in order to at least double the number classroom method. of nurses in training at any one time.

e-Learning is an innovative way to train large numbers I welcome efforts to increase the number of nurses of nurses. Most importantly, it allows nurses to remain in training, but not if it means compromising in full-time employment while they study. e-Learning is the standard and quality of training. It is important a big step in the right direction for Kenya. Technology to maintain a high level of interaction between is playing an increasingly important role in the tutors and students. If the NCK increases the size development of the modern world. We want to be a of e-learning classes, tutors may become part of that. overworked.

When I presented the idea of e-learning to my The NCK cannot just double the tutor to student ratio. colleagues at the ministry of health (MOH), they were We have made an exception for the AMREF Virtual immediately sceptical. Their main concerns were: Nursing School, permitting it to test a ratio of 50:1. We are not ready to extend this right to other schools until • Low level of computer literacy among nurses we see firm evidence that the quality of training will • Poor infrastructure in rural areas not suffer. As yet, we have not seen any such • Increased strain on health institutions evidence.

16 e-Learning and clinical care, in Kenya

AMREF is trying to encourage nursing schools to AVNS students live all over the country, not just in develop formal partnerships with all approved teaching Nairobi. Tutors need to be able to contact all their students facilities in their district, whether government, private or quickly and efficiently. The mobile support network is a faith-based. Most nursing schools participating in the more reliable source of communication than email programme have not developed formal partnerships with because internet connectivity is poor in much of the other teaching hospitals. Nurses enrolled on the country. Most nurses don’t check their e-mail regularly programme at a government nursing school cannot book as they have to go to a cyber cafe to access the internet. a clinical placement at a nearby private teaching hospital, for example. More partnership of this kind will help to relieve congestion in clinical centres. 18. The student to tutor ratio Enrolment patterns for e-learning and The potential of e-learning to repair the skills deficit distance learning among nurses in Kenya depends on achieving real economies of scale in teaching. It is essential to increase the intake of student nurses to accelerate the pace of training. According to the Nursing Council of Kenya (NCK) guidelines, one tutor should not teach a class of more than 20 students. The NCK must ensure that

Source: AMREF nurses are properly trained, and not ‘fast-tracked’ though the registered nursing diploma without adequate preparation. The same ratio is applied to the national 17. The mobile support e-learning programme, where nurses are not taught in network classrooms.

Cellular phones have become an important component of At AVNS, we have secured a significant concession. The the e-learning infrastructure. AVNS has developed a way NCK has given AVNS permission to test a new student to of contacting all our student nurses via their mobile tutor ratio of 50:1. Traditionally, tutors spend most of phones – we call it the mobile support network. All their time teaching student nurses in classrooms. At students’ mobile phone numbers are logged in a database. AVNS, as in other schools which offer e-learning, there Students are required to have at least two telephone are no classroom lessons. The majority of learning is done tutorials for each module. in computer labs. We argue that distance learning programmes enable the student to tutor ratio to be Our software, Frontline SMS from Kiwanja.net, enables increased. AVNS tutors to send out group text messages to all students. Tutors can remind students about an upcoming Students from the first AVNS class sat final exams for the exam, or about how to access a relevant medical registered nursing diploma in January 2009. document. Nurses are able to send questions to their Encouragingly, the pass rate among students who tutors via text message, which are stored within the completed the course was 93%. But not all students from computer programme. Tutors reply to individual the class made it to the national exam: ten students were questions based on their specific areas of expertise. not eligible to sit the final exam because they failed AVNS tests. They will be allowed to proceed to the final

17 Nursing The Future exam after re-sitting and succeeding in the internal tests. Health facilities are beginning to pay for their staff to A further 13 students dropped out or deferred – the participate in the e-learning programme. In my view, this flexibility of the programme allows them to postpone trend is the most reliable indicator that e-learning is assessments. Of the 27 nurses who took the national improving the quality of healthcare in Kenya. exam, 25 qualified. In July 2008, AMREF signed a memorandum of The NCK have accepted these results, but are yet to understanding (MOU) with Kenyatta National Hospital, change their official position on the statutory national the largest hospital in East Africa. Kenyatta hospital minimum student to tutor ratio. In my view, increasing committed to fund 500 of its enrolled nurses over the next the student to tutor ratio is essential, if we are to increase five years to join the e-learning programme at AVNS. In the number of nurses in training at any one time. the first year, 100 nurses from Kenyatta hospital enrolled on the programme.

19. Output and Key numbers achievements • 32 nursing schools participate in the e-learning programme Approximately 2,000 nurses graduated with a registered nursing diploma between 2004 and 2008. This total is the • 48 weeks of clinical experience needed to complete the registered nursing diploma, increased by NCK cumulative figure for e-learning, print-based distance in March 2009 from 45 weeks learning, and classroom students combined. A further 600 • 60 per cent of enrolled nurses work in rural areas nurses are expected to graduate in 2009. A further 5,798 are in training to become registered nurses. • 105 computer labs in health institutions across Kenya

To date, no national survey has been conducted to assess • 230 registered nurses trained as e-learning tutors the impact of e-learning on nursing in Kenya, although • 500 computers running the e-learning programme AVNS is preparing to carry out research on e-learning and nursing standards. AMREF relies on feedback from head • 590 nurses graduated from the e-learning programme since 2005 nurses and hospital managers to assess the e-learning programme. • 1,098 enrolled nurses qualified as registered nurses in January 2009, after completing classroom, distance learning and e-learning programmes Despite initial scepticism among senior hospital staff members, their feedback has been largely positive. Some • 2,243 nurses enrolled on the print distance learning programme at time of printing expected e-learning to add to the burden of staff shortages, but over time they have began to notice • 2,739 nurses enrolled on the e-learning programme at time of printing improvements in nursing care, notably: • 4,000 registered nurses working in Kenya in 2005 • Increased confidence displayed by e-learning nurses • 22,000: the target number of enrolled nurses to be • Improved ability to manage and treat patients without trained consulting senior nurses or doctors • Awareness of new and re-emerging medical conditions • Improved administrative and managerial skills

18 A nurse’s story

By Anne Kamene Registered Community Health Nurse Kangundo Hospital, Eastern Province

I have been working as an enrolled nurse at Kangundo I am even able to notice mistakes made by doctors. Hospital in Kenya’s Eastern Province for the past 15 Last year, a young boy with malaria and hepatitis B - years. In January 2009, I became a registered nurse, conditions that put heavy strain on the liver - was after graduating from AMREF Virtual Nursing School prescribed paracetemol by a doctor. I questioned this (AVNS) in Nairobi. on the basis that paracetemol would cause the liver to overwork. I suggested he should be given I was born in Tiva, a rural part of Kitui district, Eastern declofenac, a drug that does not react with the liver. Province, in 1972. I am a single mother with two The doctor agreed and changed the prescription. I children: a 22 year-old daughter and an 11 year-old son. would never have been able to do this when I was an My daughter was born in 1986, when I was 14 years old. enrolled nurse. She is currently in her third year of a degree in information technology at Jomo Kenyatta University Studying for a registered nursing diploma while in in Nairobi. My son lives with me, and is in his final year full-time employment was hard. On an average day I of primary school. would leave my job at 4pm, work in the computer lab until 7pm, then return home to tend to my son. I would In 1992, I joined Muranga Medical Training Centre wake up in the middle of the night to study for two in Central Province to study for an Enrolled hours from worksheets I printed at the computer lab. Community Health Nursing Certificate. The course At 6am, I would prepare my son for school before took two and a half years to complete, at a cost leaving the house for work at 7.15am. of 30,000 Kenyan shillings. I had the option to continue studying for a registered nursing diploma, but by The e-learning programme was a financial strain too. then my daughter was eight years old. I could not I had to rely on a Ksh600,000 (US$7,800) loan from afford to pay tuition fees and remain unemployed for Equity Bank. My tuition fees over the two years were two more years. Ksh117,000 (US$1,500), but I have also had to pay Ksh80,556 (US$1,045) per semester for my daughter’s My dream has always been to become a registered university fees and Ksh5,400 (US$70) per term for my nurse. I admired my colleagues who are registered son’s school fees. I had managed to save Ksh50,000 nurses for the way they care for hospital patients. They (US$650) over the years, but I lost it all in a pyramid have such detailed knowledge of everyday medical scheme. conditions. I became increasingly frustrated. In my hospital, enrolled nurses are given the most basic There was a time when I thought about giving-up responsibilities, such as dressing wounds, handing completely. My son had been doing very well at school out medication and bathing patients. I wanted to offer before I joined the programme, partly because I had my patients a higher standard of care. time in the evenings to help him with his studies. As soon as I joined AVNS, his grades began to drop, e-Learning was a new concept to me. I enrolled on the because I no longer had the time to coach him through e-learning programme in March 2007, as part of the his homework. When I discovered my son was first class of students at AVNS. The best aspect of the performing badly in school I felt so depressed. But I programme was its flexibility, allowing me to remain in decided to carry on, as I knew my nursing diploma full-time employment. I did not have to leave my job or would benefit us both in the long-run. family. Today, I am a proud to say that I am a qualified Before I joined the programme, I had never even used registered nurse. My next dream is to one day continue a computer before. To my surprise, I did not find it hard my nursing education to degree level, once I have paid to adapt to e-learning. At AMREF, we spent two weeks off all of my debts. Unfortunately, I cannot see this being coached in IT skills. I would not say that I am happening while I live in Kenya. computer literate, but I can use a computer well enough to run the programme. At the end of each month, once I make my loan repayments and taxes have been deducted from my The e-learning programme taught me many new skills. salary, I am left with Ksh3,000 (US$40) to pay for food I am more confident now, as I can diagnose and treat and bills. If I had an opportunity to work abroad, I a wide range of medical conditions, from mental would grab it with both hands. I know I would be able illness to infectious diseases. Previously, I would rely to earn a higher wage in the UK or US. on advice from senior nurses and doctors. Today, I can treat more patients independently.

19 Nursing The Future

20. Funding and governance • The Fresenius Foundation, the charitable trust of a global healthcare company, has funded staff salaries and e-Learning a specialist skills lab at AVNS. The skills lab is equipped Accenture and the Accenture Foundations funded a large with anatomical dummies and medical apparatus proportion of the e-learning programme, contributing commonly found in most hospitals in Kenya. Nurses are US$2.9 million over a five-year period. A cash donation able to practise essential clinical skills before formal of US$1.7 million has been provided by the Accenture assessments. Foundations. Funding is due to expire in 2010. • PSO is an association of Dutch civil society Negotiations are underway, with a view to securing a organisations which funds innovation and capacity further contribution of US$290,000 to support the building in the developing world. They have funded ongoing development and roll-out of the e-learning initiatives including production of DVDs of clinical programme. demonstrations; procurement of laptops from

The balance of US$1.2 million is calculated on the basis Computer Aid, a UK charity; and monitoring and of pro bono services, including 14,500 hours of IT evaluation. support from Accenture Learning Services. The staff time The steering committee donated by Accenture Learning Services was dedicated The e-learning programme has brought together private primarily to designing software and training AMREF staff enterprises, faith-based institutions, international charities in computer programming. No other donors have and the Kenyan government. Early on, AMREF contributed to the national programme. recognised the potential for conflicting agendas. From inception, AMREF established a steering committee on Tuition fees generate the balance of funding. Nurses are which all the different stakeholders are represented, required to pay about US$1,500 in course fees over the including the MOH, NCK, Accenture and nursing two years. Fees are paid directly to nursing schools, to schools. cover the costs of administering clinical assessments. No other state subsidies or funding are directed to support the The steering committee is mandated to: programme. • Approve management decisions relating to the AVNS administration of the e-learning programme: e.g. AVNS is funded separately from the wider e-learning location of computer labs, distribution of personnel. programme. AVNS was set-up in 2007 – mid-way • Develop strategies to increase total participation by through the programme – in response to a need for nurses on the programme. practical solutions to challenges faced by nursing schools • Develop ways to improve the e-learning methodology. which had adopted the methodology developed by AMREF. No money was earmarked for AVNS in the The steering committee has no power or jurisdiction over funding from Accenture. AVNS has secured funding from the teaching curriculum. It can only make suggestions to other donors, principally: the relevant authorities to update or amend the national syllabus. All decisions relating to the nursing curriculum • Flying Doctors Society of Africa, an AMREF are the responsibility of the NCK and MOH. programme which offers emergency evacuation services to critically ill patients in remote areas, provides US$20,000 a year in unrestricted funds.

20 e-Learning and clinical care, in Kenya

A report from the wards 21. The brain drain Africa has a history of skilled health workers emigrating By Philomena Maina Chief Nurse to developed countries in search of better paid jobs. Kenyatta National Hospital National health systems catering for aging populations in Kenyatta National Hospital (KNH), formerly King Europe and America have created a high demand for George VI, was established in 1901. It was the first skilled health workers, offering higher pay and better hospital built in Kenya specifically for the native population. With 1,800 beds, KNH is Kenya’s largest working conditions. health facility, and second largest in Africa. We offer a full range of specialised medical care, from burns In 2009, AVNS conducted a survey of 27 graduates from treatment to open-heart surgery. Doctors at KNH rely heavily on nurses in the provision of medical treatment. the e-learning programme. Respondents were asked whether it was their long-term aim to continue working as The standards of care provided by hospitals are changing due to innovations in medical practice. nurses in Kenya. Of 27 interviewees, 20 nurses expressed Treatment is increasingly specialised and a desire to migrate to either Europe or America. Low sophisticated. The expectations of patients are also higher. Medical professionals need to be able to wages were cited as their main motivation for wanting to respond to these changes. leave. Most of these nurses worked for government health

KNH employs 800 enrolled nurses. In 2008, we signed institutions. a memorandum of understanding with AMREF Virtual Nursing School. Over five years, KNH has agreed to Enrolled nurses in Kenya are paid between US$100 and pay for 500 of our enrolled nurses to train for a registered nursing diploma through e-learning. The US$250 per month, depending on location and employer. programme is convenient for KNH. Nurses are not They are not guaranteed a pay rise when they receive their required to take extended periods of leave, minimising the strain caused by shortages of staff. Because registered nursing diploma, particularly in government nurses remain in full time employment, we are able to institutions. No new funds have been made available by monitor and evaluate their progress. the MOH to increase salaries of nurses who complete the e-Learning promises an efficient way to bring large registered nursing diploma. numbers of experienced nurses up to speed with modern day nursing practice over a relatively short period of time. Classroom education is still The probable impact on migration of an increase in the relevant, particularly for students who have never aggregate number of registered nurses is difficult to practised nursing before. They need regular face-to-face interaction with tutors. predict. However, anecdotal evidence from nurses implies that e-learning may reduce the likelihood of qualified Experienced nurses are building on what they already know. They are familiar with the nurses seeking new employment abroad. By enabling fundamentals of nursing care. With e-learning, nurses to continue to work and study without leaving nurses will learn about a new aspect of clinical care in the computer lab. The next day, they can put their local communities, distance learning in any form is less new knowledge into practice. e-Learning enables disruptive to family and other social networks than nurses to grasp new skills efficiently. traditional tuition in classrooms. If it can be demonstrated KNH have not conducted a formal survey to that e-learning encourages 'stickiness' - that is, the evaluate the impact of e-learning on clinical care. Personally, I have noticed the following propensity of nurses to continue to work in their local improvements: communities - then improvements in local capacity are

• Confidence in clinical areas more likely to be sustained. • Ability to clearly articulate medical symptoms • Diagnosis of medical conditions • Management of time • Interaction with senior nurses • Research into unfamiliar medical conditions

21 Nursing The Future

22. Recommendations hospitals have sought to address these constraints. Partnerships have been one of the key achievements of The brain drain is a real and urgent concern for Kenya’s AVNS, and provide an example to other medical schools. health sector, and in every African country. According to After long delays and problems of congestion at clinical most forecasts, Kenya will fail to achieve the targets for sites during the initial phase of the e-learning programme, public health in the Millennium Development Goals by student nurses at AVNS are able to schedule clinical 2015. The combined impact of population growth, placements at teaching hospitals without significant urbanisation and poor sanitation has contributed to a problems. All medical schools should give priority to rising incidence of infectious diseases. developing:

In reality, it is not feasible to stop skilled professionals • Formal partnerships with teaching hospitals whether in from seeking better paid jobs abroad. Nor, even if it were the state, private, or faith-based sectors. desirable, would it be morally defensible to impede the • Mechanisms to improve and facilitate access to clinical movements or ambitions of Kenyans who seek to placements for student nurses. participate in the global economy. External support has been invaluable in the Equally, Kenya cannot afford to lose large number of development of AMREF’s e-learning programme. Its health professionals. The costs of training nurses, in both achievements to date would not have been possible time and national resources, are high. A qualified without contributions, both financial and technical, from registered nurse is likely to have completed at least three Accenture, the global consulting and technology services and a half years of professional training. For as long as group. Designing systems which are consistent with the skilled migrants choose to leave Africa, governments accounting and other practices of potential donors can must give priority to training health workers. substantially improve the prospects of securing help.

Improving capacity to train nurses and other In e-learning, technical advice and ‘in-kind’ assistance professional staff is the only viable policy response to the can have a greater lasting impact on the capacity of local skills deficit. By offering opportunities for enhanced health institutions than financial grants. This must be training and qualifications to nurses in work, the given priority in planning new programmes. In our prospects of skilled nurses emigrating may even be experience, it can be easier to obtain cash from donors reduced. Nurses who are not required to re-locate to than to secure technical support or pro bono professional established teaching centres, leaving their homes and assistance. families, may be less keen to migrate after graduation. Improved skills are likely to bring more responsibilities Accenture’s experience software design was and job satisfaction for nurses, without a change of indispensable to the development of a ‘scale-able’ employer or country of residence. e-learning programme which could be rolled out across the country. The experience of ‘scaling up’ the AMREF Nursing schools are the primary facility for professional programme in Kenya argues for: education, in partnership with teaching hospitals and other clinical facilities. In Kenya, the capacity of these • Sound technical support in the early stages of software institutions to absorb high numbers of additional students development. seeking clinical placements is limited. At AVNS, new • Giving precedence to ‘in-kind’ technical assistance in partnerships between the nursing school and teaching the design period, and for the duration of the pilot phase.

22 e-Learning and clinical care, in Kenya

• Channelling financial sponsorship or donations to The United States, United Kingdom and South Africa are support the roll-out and ‘scaling up’ of e-learning the principal destinations for Kenyan nurses working systems. abroad. The governments of these countries should consider compensating Kenya by contributing to The mobile support network incorporated within the initiatives to build the capacity of medical schools and AMREF e-learning software makes use of cellular phones teaching hospitals in Kenya. to compensate for poor or interrupted internet connectivity. Tutors are able to contact students directly, Options for reparations of this kind include: either individually or as a group, via cellular phones. A • Financial support for health institutions mobile support network is an highly practical innovation • Subsidies for student nurses for any distance learning programme, whether e-learning • Provision for clinical training and experience, in Kenya or based on more traditional textbooks. Medical schools or abroad and other training centres should adopt similar platforms • Supply of training equipment to take advantage of the popularity of mobile phones in • Secondment of skilled personnel Africa.

Policy makers should encourage international debate to The student to tutor ratio is a key determinant of the develop a formula for reparations, whether financial or gains in reach and scale made possible by e-learning. In other forms of ‘in kind’ assistance, in proportion to the Kenya, the goal of re-training 22,000 nurses within nine numbers of African health professionals employed abroad years will not be achieved without significant economies in the health systems of their host countries. of scale by comparison with classroom teaching. The Nursing Council of Kenya requires a maximum student to tutor ratio of 20:1 for classroom teaching and for any form of distance learning, with the exception of the programme administered by AVNS.

AVNS has been granted a special dispensation to run e-learning programmes with a student to tutor ratio of 50:1. Although this dispensation recognises AMREF’s contribution to increasing the aggregate total of nurses in training for the registered nursing diploma, other institutions which participate in e-learning programmes need to demonstrate their capacity to train nurses effectively at the higher student to tutor ratio.

Reparations for the loss of skilled health professionals from Africa to industrialised nations are a vexed and politically sensitive issue. However, effective e-learning systems represent a viable, concrete method by which wealthy countries might contribute to building new clinical capacity in Africa.

23 Available from Africa Research Institute NURSING THE FUTURE e-Learning and clinical care, in Kenya By Angela Nguku

Much has been said about the promise of information technology to transform Africa. Already, cellular phones and internet cafes connect rural villages to distant cities and international markets. This new electronic infrastructure promises to extend education and training far beyond the geographical constraints of an old-fashioned classroom. In this new world, old ways of learning can be harnessed to the emerging powers of technology: a process of evolution, as much as revolution.

Few tests of the new methods of e-learning can be more exacting than to improve standards of clinical care by hard-pressed nurses in Kenya’s busy hospitals and clinics. But such is the ambition which drives the country’s first nationwide e-learning programme for nurses, devised by the African Medical and Research Foundation (AMREF). Its ultimate goal is to upgrade the skills of 22,000 working nurses to equal the demands of managing epidemics such as HIV/AIDS, often in an environment of rapid urbanisation and poverty.

In this candid and detailed account, Angela Nguku chronicles the evolution of e-learning among nurses in Kenya. From her perspective as coordinator of the AMREF Virtual Nursing School in Nairobi, she charts both the obstacles – a shortage of qualified tutors, the scarcity of clinical placements – and the priorities to overcome them. Kenya is widely expected to fail to meet the United Nations’ Millennium Development Goals for health by 2015, but the lessons of e-learning indicate an alternative and important path to improving standards of care.

Africa Research Institute